Structure and markers of appropriateness, quality and performance of drug treatment over a 1-year period after hospital discharge in a cohort of elderly patients with cardiovascular diseases from Germany

Abstract

In a group of elderly patients over 65 years of age with at least two cardiovascular diagnoses requiring chronic medication (n=424), drug therapy at hospital discharge and at home thereafter was followed for a 1-year period. Two home visits took place at 3 months and 12 months after initial discharge. A median of six prescriptions had already been given at the time of discharge; this number increased slightly during ambulatory follow-up. After 1 year, about 30% of the patients had to take more than ten dosing units per day. After discharge, about 50% of all prescriptions were subject to changes in the choice of the preparation (brand-generic) or the agent used [within a class of similar agents, e.g. angiotensin converting enzyme inhibitors (ACIs)]. The prescription of some problematic agents (benzodiazepines, non-steroidal anti-inflammatory agents) increased during the ambulatory follow-up, but pivotal medications for cardiovascular indications (e.g., ACI) given at discharge were maintained. Over-the-counter (OTC) drugs—which were not part of the discharge medication—contributed to 12% of all drugs taken at V4. The majority of the prescriptions (95% of about 2,000 prescriptions surveyed at each visit) was in agreement with the drug’s approval status and was appropriate in terms of absence of contraindications. At home visits, therapy with ACI or beta-blocking agents was in agreement with clinical guidelines, although under-dosing was obvious. Blood pressure control (<140/90 mmHg) was achieved in 61% of the patients at discharge and deteriorated to 45% after 1 year; international normalized ratio control in patients with oral anticoagulation also declined (control rate 57% at discharge, 46% after 1 year). Statins as secondary prevention were given at discharge in only 60% of suitable patients, declining to about 50% in ambulatory visits. Diabetic control was not present in 35% of the patients at discharge or at home. Properties of or reason for their medication could be given for the majority (70–80%) of the prescriptions; these quotations were, however, cursory and almost nothing was known about medication risks. At home visits, non-compliance was admitted for approximately 8% of the prescriptions. In conclusion, for pivotal indications, family doctors widely followed the discharge recommendations, but deficits in ambulatory prescriptions and poor performance of the medication were in part already employed at the time of discharge from the hospital. The lack of a patient’s knowledge about their own medication is precarious.